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CPRS – our EMR One centrally-developed application, “CPRS” (Computerized Patient Record System) A Delphi view of a Mumps Database Built upon component results-reporting systems of laboratory, pharmacy, radiology over 24 years “Complete” GUI EMR only since Feb 1998 Many iterations – currently on version 26 “Next Generation” EMR (web-xml based) under development Additional partner applications all grouped together under the umbrella of “VistA”

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Lessons Learned Automated order entry is a sustainable method for influencing ordering behavior An effective order entry system should provide extensive order configuration tools Substantial work is needed to optimize ordering systems (both to make them effective and to obtain provider buy-in) A multidisciplinary effort is needed to assure that all problems/concerns/issues are considered

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Other EMR safety features: availability and display of information Legible notes and orders Consolidation of important components of record Accessible from multiple locations Accessible by multiple providers Elimination of transcription error with provider order entry Cover sheet displays pertinent data, for example, eligibility, vital signs, immunizations, location of patient, next appointment, Next of kin, address and phone number easily available Ability to obtain data from remote sites (both outlying clinics and other national centers)

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Integrated Technology Projects VistA Imaging (scanned images; ECGs, endoscopy and other clinical images) available at any workstation Full PACS implementation with radiology, nuclear medicine, and ultrasound images available on-line at any work-station Full interconnectivity of all local VA facilities Access to clinical records from any VA facility nationwide Off-site access to full suite of clinical applications for on-call MD staff

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Cedars-Sinai Medical Center, the largest private hospital in the West, is suspending use of a multimillion-dollar computerized system for doctors' orders after hundreds of physicians complained that it was endangering patient safety and required too much work. Ironically, the computer software was designed to do the opposite: Reduce medical errors, allow doctors to track orders electronically, and warn them about dangerous drug interactions and redundant laboratory work. But, from the start of its rollout in October, the Patient Care Expert program, dubbed PCX, has been plagued with problems, many doctors said. … …This week, Cedars-Sinai suspended the ordering system after more than 400 physicians confronted hospital administrators at a tense staff meeting Friday. The doctors voted nearly unanimously to urge the hospital to halt the system until the problems are fixed. More than a dozen Cedars-Sinai physicians interviewed by The Times said they experienced problems ordering medication, tests and supplies using the PCX software. One patient with heart failure did not receive the pills his physician ordered until he mentioned it to a nurse. Another patient did not receive a walker until three days after it was ordered. A baby was given local anesthetic for a circumcision one day early. CALIFORNIA Hospital Heeds Doctors, Suspends Use of Software Cedars-Sinai physicians entered prescriptions and other orders in it, but called it unsafe. Los Angeles Times January 22, 2003 Los Angeles Times January 22, 2003

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Point-of-Care Reminders to Influence MD Behaviors Prompt providers when important health measures are needed for patients ◦ Reports available to verify diagnoses; verify appropriate treatment given; identify patients requiring intervention; validate effectiveness of care ◦ Data can be aggregated at the facility or national level with the use of standard terminology, thus allowing preventive health measures to be aggregated and compared Prompts for care are linked to structured data- entry tools Data is recorded for aggregated (and individual) reporting

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Current targets Transformational Initiatives: ◦ Patient-Aligned Care Teams (Medical Home) ◦ Chronic Disease Management using Telehealth ◦ Health Promotion and Disease Prevention as an integral part of primary (and other) care ◦ Realigning Care to be Veteran-Centric  At the time of the patient’s choosing  Open access to all clinic (currently 98% within 14d)  Home and on-line care